Referral Agent's DBA Name

If you are not using an agent, please leave blank.

LEGAL BUSINESS INFORMATION

Legal Entity Name *

Business name used on your tax forms

Legal Entity Address *

Legal Entity Country *

Legal Entity Zip Code *

Legal Entity State *

Legal Entity City *

Legal Entity Phone *

Type of Ownership *

Sole ProprietorCorporationLLC

State of Formation *

Fed Tax ID Type *

Federal Tax ID or Social Security Number>/P>
FEINSSN

FEIN or Social Security Number

Year Business Established *

Years in Business *

Years Business Owned by the Current Owner *

Any Prior Bankruptcy? *

NOYES

Type of Bankruptcy

N/ABusinessPersonal

Bankruptcy Date

PRIMARY CONTACT INFORMATION

Contact Full Name *

Contact Email *

Contact Phone *

Contact Mobile *

BUSINESS CONTACT INFORMATION

Business Contact Email *

Business Contact Phone *

Customer Service Phone *

Does your business have a website? *

YESNO

Primary Website Address

Website URL #2

If you have multiple URLs for one merchant account.

Website URL #3

If you have multiple URLs for one merchant account.

Website URL #4

If you have multiple URLs for one merchant account.

TECHNICAL CONTACT INFORMATION

Technical Contact Full Name *

Technical Contact Email *

Technical Contact Phone *

FUNDS SETTLEMENT BANK INFORMATION

Bank Name *

Bank Contact Name *

Bank Phone *

ABA Rounting Number *

Bank Account/DDA Number *

Industry Type *

AdultAlcohol & WineBail BondsBizopsCBD CannabidiolDatingDebt Collection AgencyDebt Consolidation/Credit RepairDocument PreparationE-cigarette & VaporEducational SeminarsElectronicsExtended WarrantyFirearmsFurniture & Home ImprovementGamingGold & Precious MetalsHigh RiskJewelryMarijuanaMortgage Loan ModificationMoving & TransportationMulti level MarketingNutraceuticalsPet Supplies & CarePharmaciesSEO MarketingTech SupportTobacco & CigarettesTravel AgencyVOIP & TelecommunicationsOther

If not listed above, please fill in the industry type here

GOODS & SERVICES

Type of Goods/Services *

Digital ServicesHard GoodsOther

Describe the Goods/Services Provided *

Percentage Provided by Internet *

All percentage provided by Internet, Mail Order & Phone must = 100%.

Percentage Provided by Mail Order *

All percentage provided by Internet, Mail Order & Phone must = 100%.

Percentage Provided by Phone *

All percentage provided by Internet, Mail Order & Phone must = 100%.

Goods/Services Delivery Period *

All percentage provided by Internet, Mail Order & Phone must = 100%.
Immediate or 1 day02-10 days11-30 days31-90 days91-180 days> 180 daysOther

If Other, please describe further.

Average Days for Delivery *

Bought goods from a vendor? *

Please put the name of the vendor here. If you do not purchase your goods from a vendor, please put "No"

Vendor Address *

Refund Policy *

No RefundsRefunds within 30 daysDamaged/Defective OnlyRestocking FeeStore Credit OnlyReturn Auth RequiredOther

If Other, please describe further.

Do you charge a Restocking Fee? *

SelectYESNO

Is a deposit required on any sales? *

SelectYESNO

Deposit Percentage

If you answered "yes" above, what percentage of the sales is required?

MARKETING METHODS

If "Other Marketing", please describe further

PRODUCT FULLFILLMENT

Do you use product Fullfillment Services? *

YESNO

PROCESSING SUMMARY & HISTORY

Do you have any processing history? *

YESNO

PCI-DDS COMPLIANCE

Do you store credit card data? *

SelectYESNO

Any data breaches? *

SelectNOYES

Are you PCI compliant? *

CompliantNoncompliant

If no, please explain.

PCI Compliance Date *

How do you secure your data? *

Do you use a website host provider? *

selectYESNO

Who is your host provider?

PRINCIPAL #1 INFORMATION

Principal First Name *

Principal Last Name *

Principal Title *

PresidentVice PresidentTreasurerOwnerPartnerCEOSecretaryDirector

Principal Percentage of Ownership *

Principal Home Address *

Principal Zip Code *

Principal City *

Principal State*

Does the Principal own or rent a home? *

OwnRent

Years Principal lived at current home? *

Principal Home Phone *

Principal Mobile Phone *

Principal Email *

Principal Country of Citizenship *

Principal Social Security Number *

Principal Date of Birth *

Government Issued ID Type *

Drivers LicensePassportOther ID

Government Issued ID Number *

Government Issued ID State *

Governement Issued ID Expiration Date *

Name of Relative not living with you *

Phone Number of Relative Not Living with you *

LEGAL BUSINESS INFORMATION

IF THERE ISN'T A SECOND PRINCIPAL, SKIP TO THE BUSINESS LOCATION INFORMATION SECTION

Principal #2 First Name

Principal #2 Last Name

Principal #2 Title

SelectPresidentVice PresidentTreasurerOwnerPartnerCEOSecretaryDirector

Principal #2 Percentage of Ownership

Principal #2 Home Address

Principal #2 Zip Code

Principal #2 City

Principal #2 State

Does Principal #2 own or rent a home?

SelectOwnRent

Years Principal #2 lived at current home?

Principal #2 Home Phone

Principal #2 Mobile Phone

Principal #2 Email

Principal #2 Country of Citizenship

Principal #2 Social Security Number

Principal #2 Date of Birth

Principal #2 Government Issued ID Type

Drivers LicensePassportOther ID

Principal #2 Government Issued ID Number

Principal #2 Government Issued ID State

Principal #2 Government Issued ID Expiration

Name of Relative not living with you

Phone Number of Relative Not Living with you *

BUSINESS LOCATION INFORMATION

Type of Zoning for your business *

CommercialIndustrialResidental

Type of Premises *

Office BuildingResidenceInternet (Unified Only)Other

If Other, please describe further.

Square Footage of the Location *

0-500501-20002001+

Premises Ownership *

OwnRentLeaseOther

If Other, please describe further.

Multiple Business Locations *

SelectYesNo

Number of Locations *

PLEASE UPLOAD FOLLOWING DOCUMENTS

Certificate of Incorporation*

Tax ID document/ SS4*

Owner's driver's license*

Void check for each of the bank accounts where deposits can be made (please do include the month and year when the account was opened)*

**REMINDER** IF YOU ARE WORKING WITH A REFERRAL AGENT, PLEASE EMAIL THEM YOUR SUPPORTING DOCUMENTS.